2.6 Records and Documentation
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Last Modified:
02-Aug-2023
Review Date:
01-Jun-2019
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| Purpose |
To inform residential care workers about their record keeping responsibilities. |
| Practice Requirements |
- Public officers must create and maintain public records to meet legislative and policy requirements.
- Residential care workers must adhere to record keeping standards outlined by the Department, such as Naming Guide for Client Documents in Objective (in related resources) and follow the correct procedures for filing client related documents and emails in Objective.
- All client related information must be recorded in Assist and stored in an appropriate client file on Objective within, where practical, a 48 hour timeframe.
- Department workers must only collect and manage information that is relevant, reliable and complete, and needed to fulfil the Department's responsibilities to the government and community.
- All residential care workers must compose reports that are clear, objective, concise and professional. This applies to the residential group home’s care planning documentation, Log Book, case notes, medical records, the home’s diary, search and seizure register, neighbourhood complaints book and any other official documentation.
- All appointments must be recorded in the home’s diary.
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Procedures- Residential care plans and reviews, trauma profiles and safety plans
- Log Book
- Case Notes
- Handover
- Other important documents
- Diary
- Weekly team meeting minutes
- Medical records and Medication Charts
Residential care plans and reviews, trauma profiles and safety plansResidential care planning includes tasks such as developing residential care plans, care plan reviews, trauma profiles and safety plans in accordance with relevant policies. Once completed these documents must be stored in the child’s residential care objective file. Log BookThe Log Book is used to record events occurring within the home. The Log Book is a legal document and must not be used for personal comments and communications. Log Book entries must:
- inform residential care workers where additional information can be found for example, a Critical Incident report
- record the names of residential care workers coming on and going off shift and the time at the beginning of each shift
- record the names of the current children and their whereabouts at the beginning of each shift
- record the petty cash balance and the number of keys at the beginning of each shift
- record names when recording information about specific people and places (for example, John Smith (residential care worker) taking Peter Brown and Robert Green to Perth High School)
- record the day and date at the top of each page
- be in chronological order, with the time written in the left hand margin
- be initialled in the right hand margin by the residential care workers making the entry
- have a line left between entries
- be accurate, concise and objective
- when an entry is recorded out of chronological sequence, write “Late Entry” next to the time.
Case NotesThe case notes are used to record all relevant information about each individual resident. They should reflect the child’s residential care plan and safety plan. Case notes must be completed towards the end of every shift. Case notes should be as detailed as possible, while remaining objective. When completed, case notes must to the child’s residential care Objective file. HandoverA handover form should be completed each shift by the outbound staff to inform the incoming staff of relevant information. Outbound and incoming staff are to electronically sign the handover form and save in the House Objective Shift Handover Notes folder each shift.
Information should be included noting: - date
- shift handover type
- full names of outbound and incoming staff
- child whereabouts and demeanour
- child shift events
- house dynamics
- any escalations and/or recent critical incidents
- recent triggers
- child medication
- check of petty cash, house keys, car keys and food card
- tasks for incoming shift
- tasks for every shift
- recent Solvsafety reports
- any staff safety notes
- new hazards, child behaviours or risks identified with controls/strategies implemented
- general information/reminders
Other important documentsAll other relevant documentation relating to a child’s care received by the residential care workers should be sent to case managers to be stored appropriately. DiaryAll appointments must be recorded in the home’s diary. Diary entries should state all relevant information clearly (who, who with, who organised it, where, when, how getting there, how getting back, when due back, does it need confirming).
Weekly team meeting minutesAll weekly team meeting minutes should be recorded and include the following information: date, time, attendance, relevant children and operational information. Minutes should be saved on the appropriate Objective file and made available to all residential care workers.
Medical records and Medication ChartsImportant medical information is discussed and recorded when a child is placed in the home. Discussion must include information about medical alerts, medication and any other health concerns. Medication Charts must be completed before any medication is administered to the child. Residential care workers must sign this form stating that the medication was offered and taken. Alternatively, a refusal should be recorded as such. Each child’s Medication Chart must be scanned into his or her Residential Care Objective file regularly. For more information refer to 6.6 Health and Medication.
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